Africa is a vast and diverse continent. The diversity relates not only to geography but also languages, cultures, religions and histories. However, conflict, disease, poverty and political instability are common characteristics. Notwithstanding commonalities, to pronounce on Africa in general is problematic. To comment on mental health systems in Africa, and how to strengthen them - one needs an understanding of weaknesses. Again, to presume that one can pronounce on Africa as a continent may indeed be presumptuous. That having been said, the content which follows will provide, at worst, points of departure for discussion and debate - with the intention of identifying a way forward for a continent without losing sight of country specific issues.

Anxiety disorders are common, distressing and impairing conditions - but many people remain undiagnosed and the standard of care received is usually sub-optimal. Although advances in genetics, neuroscience, pharmacology and psychology research have all deepened our understanding of anxiety disorders, on an individual basis it remains difficult to predict who will become troubled by symptoms and difficult to make treatment decisions which would result in better clinical outcomes for the patient.

The European and South African Research Network in Anxiety Disorders (EUSARNAD) aims to provide an international collaborative network for sharing clinical databases, refining research methodologies, and developing and evaluating innovative treatments for patients with anxiety disorders. EUSARNAD thereby contributes to initiatives to enhance understanding of the causes of anxiety disorders and to the development and improved delivery of improved treatments. During the two-year programme, individual exchange researchers are affiliated to research active teams in each of the participating institutions. They gain access to the knowledge and expertise at each participating centre and are also able to attend local postgraduate training programmes within the host institutions.

Desomorphine, a synthetic opioid, can be synthesised from codeine, red phosphorous and iodine, however, the end result is impure and highly corrosive. The street name is 'krokodil' due to the characteristic skin scales users have after use. The effects on the user are similar to that of heroin, although they are reduced from 4-8 hours for heroin to 1 hour for homemade desomorphine. Due to the impure nature of krokodil, phlebitis and gangrene are common. Tissue damage is drastic and it is believed that users' life expectancy is only 2-3 years.

Charcot-Marie-Tooth disease (CMT), also known as Hereditary Sensory Motor Neuropathy (HSMN) is the most common inherited peripheral neuropathy and it can follow autosomal dominant, X-linked, autosomal recessive and even a sporadic inheritance pattern. Very few studies have evaluated psychiatric problems in this disease, but there is a 30% lifetime prevalence of psychiatric disorder in patients with CMT. Depression and phobic disorder are commonly occurring psychiatric comorbidities. After obtaining informed consent, we report the case of a patient with Charcot-Marie-Tooth disease presenting with a manic episode and the treatment thereof with sodium valproate.

Objective : The aims of this study were to determine the prevalence of metabolic disorders in long-term psychiatric patients, and the relationship between known risk factors and these metabolic disorders.

Method : All psychiatric in-patients ≥18 years, who had been admitted ≥six months were invited to participate. Eighty-four patients participated. They were interviewed, examined, measured and blood tests conducted to determine several demographic and clinical variables including age, gender, weight, blood pressure and fasting blood glucose.
Results : The prevalence of the metabolic disorders were: metabolic syndrome 32%, hypertension 32%, diabetes mellitus 8%, cholesterol dyslipidaemia 32%, triglyceride dyslipidaemia 29%, low density lipoprotein (LDL) dyslipidaemia 50%, overweight 37%, and obesity 24%. Black African and female patients were more likely to have metabolic syndrome. Female patients were more likely to have cholesterol dyslipidaemia and obesity. Hypertension was associated with age. Ninety-six percent of patients with dyslipidaemia were newly diagnosed during the study. Three out of the seven previously diagnosed diabetic patients had raised fasting blood glucose levels.
Conclusion : The prevalence of metabolic syndrome falls towards the lower limits of the expected prevalence rate. Race and gender showed a moderate statistical association with metabolic syndrome. There is a lack of screening for dyslipidaemia in this setting. Diabetic patients should be referred to specialist diabetic clinics for better monitoring and control.

Objective : This study examined the competence and accuracy of ad hoc interpreters in interpreting key psychiatric terms at a South African psychiatric hospital.

Method : Nine individuals were asked to translate key psychiatric terms from English to Xhosa. These translations were then back-translated by independent translators, who do not have knowledge of psychiatric terminology. These back-translations were then compared with the original English.
Results : It was clear that not all the participants were fully competent in English. None had formal training in interpreting or psychiatric terminology. Not all of the participants were familiar with the psychiatric concepts that clinicians use and they often made mistakes while interpreting.
Conclusion : The competency levels of interpreters are unsatisfactory to ensure the optimal delivery of mental health care. It is clear that there is a need for trained interpreters in South Africa, as the continuous use of untrained interpreters compromises the effectiveness of mental health care and could lead to adverse health outcomes.

Objective : The psychological impact of the South African border war on veterans has received little or no attention. This study determined the prevalence of post-traumatic stress disorder (PTSD), and extent of resilience among a cohort of veterans.

Method : Of 1527 former students who matriculated from a Johannesburg high school from 1975 to 1988, only 109 were reachable for convenience and snowballing recruitment into this study. An anonymous, internet-based questionnaire was used to obtain information on demography, combat exposure, drug and alcohol use, traumatic events in later life, and recourse to medication and counselling. The Impact of Event Scale - Revised (IES-R) assessed for PTSD and the Connor Davidson Resilience Scale (CDRISC) measured resilience. Data were processed with STATA; version 11 statistical software package. Analysis included Chi square test and regression analysis.
Results : The response rate was 49.5% (n=54). The prevalence of PTSD was 33% and significantly associated with combat exposure (p=.012). Despite high prevalence of PTSD in those exposed to combat, 94% showed normal to above-normal level of resilience. CD-RISC scores showed no association with the IES-R. Only current cannabis use was significantly linked with PTSD (p=.044).
Conclusion : Although the prevalence of PTSD found in this sample was higher than in comparable international studies, this cohort of former SA national servicemen, showed high levels of resilience. The current use of cannabis within the context of prior exposure to military national service or combat should prompt clinicians to screen for the presence of PTSD-associated symptoms.

Objective : This study analyzes the relationship between informants' age and their assessment of mental health needs in post-conflict society and examines if mental health needs assessment priorities differ depending upon whether or not the informant was exposed to the Liberian civil war.

Method : A cross-sectional survey was conducted in March 2009 to obtain data on mental health needs of Liberian children, adolescents and young adults. A total of 171 individuals were interviewed. The data were analyzed using a two-way ANOVA.
Results : Elder respondents expressed a preference for young adults to receive services in a church/mosque (F = 4.020, p < .05); for adolescents in volunteer programs (F = 3.987, p < .05) and for children in sports programs (F = 4.396, p < .05). Experiencing conflict did exert some influence on treatment setting preferences. Those who resided outside Liberia during the conflict cited a preference for traditional healers and medical clinics. However, this preference was for the children and young adult age categories. Those who experienced the civil war reported significantly higher preferences for adolescent services to be located in medical clinics, with traditional healers, and in churches/mosques.
Conclusion : This study provides additional support for the premise that the utilization of psychiatric services needs to be viewed from the perspective of Liberians and that there are differences in preferences across groups. Our results suggest that service providers and policy makers take into account the age of the patient when deciding where to locate treatment settings for the population.

Objective : The aim of this study was to report on the prevalence of cognitive impairment, and to assess the performance and utility of subjective, objective and informant screening tools in a heterogeneous community sample.

Method : A sample of 302 elderly participants (>60 years) living in residential homes in a large city in South Africa were screened for the presence of cognitive impairment using objective (Mini-Mental State Examination [MMSE] and Six Item Screener-[SIS]), subjective (Subjective Memory Complaint [SMC]and Subjective Memory Rating Scale [SMRS]) and informant (Deterioration Cognitive Observee [DECO]) screening tools. All tools were compared to the MMSE and the influence of demographic variables on the performance on these tools was considered.
Results : Significantly lower MMSE scores were found in participants aged 80-89 years (p=.023) and those who had 8-11 years of education (p=.002). For every one additional year of education, participants were 0.71 times less likely to screen positive on the MMSE. Differential item functioning on various components of the MMSE was demonstrated due to the effects of education, race and gender. There was significant differential performance between the recommended and alternate attention/concentration items (p<.001) with the alternate item favouring better performance. Based on the MMSE cutoff score of < 23, the prevalence of cognitive impairment was 16.9%; the prevalence yielded by the remaining tools ranged from 10.5% using the DECO to 46% as determined by the presence of a SMC. Using the MMSE as the reference standard for the presence of cognitive impairment, the SIS, SMC, SMRS and DECO had sensitivities of 82.3%, 54.6%, 17.0% and 37.5%, and specificities of 71.3%, 57.6%, 87.4% and 96.7% respectively. Age and race influenced performance on the MMSE, SIS and SMRS.
Conclusion : Different types of cognitive screening tools yielded varying sensitivities and specificities for identifying cognitive impairment when compared to the MMSE. The influence of race, age and education on test performance highlights the need for suitable, culture-fair screening tools. Locally, the alternate item for attention/concentration should be preferred.

Objective : To describe the demographic, clinical and risk profile of Mild Cognitive Impairment and dementia in a sample of elderly South Africans within a residential setting.

Method : One hundred and forty participants residing in a group of residential homes for the elderly were assessed by psychiatrists and assigned diagnoses of dementia or Mild Cognitive Impairment (MCI). Participants diagnosed with dementia were also offered haematological investigations and a CT scan of the brain.
Results : The sample consisted of 140 participants comprising 46.4% White, 29.3% Coloured, 20% Asian and 4.3% Black participants. There were 97 (69.3%) females and 106 (75.7%) participants had less than 12 years of education. Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Increasing age was associated with cognitive impairment (MCI and dementia) (p=.020) but there was no association between gender and cognitive impairment (p=.165). MCI was significantly associated with a lower education level (p=.036) and no association was found between depression (current-p=.646; past-p=.719) and dementia or MCI. The presence of vascular risk factors (n=140) ranged from 66.4% (hypertension) to 14.3% (stroke). Subjective memory complaints were significantly associated with cognitive impairment (p=.001). Except for the use of the telephone (p=.225) and the television (p=.08), impairment in all domains of instrumental activities of daily living that were assessed were significantly associated with a dementia diagnosis.
Conclusion : The study showed that cognitive impairment was associated with increasing age and low education levels. The presence of vascular risk factors places this population at risk for future cognitive decline.

An epic-historical film presented itself in the form of Lincoln, the movie I chose for this edition of the Journal. I wonder how many of you guessed the title of this review correctly... Set in 1865, with Abraham Lincoln entering his second term of office, the film mainly revolves around Lincoln (played by Daniel Day-Lewis) trying to get the landmark Thirteenth Amendment to the United States Constitution passed through Congress. The brutal Civil War, also known as the 'War between the States', was in its fourth year, a war that claimed the lives of many soldiers on both the Union and Confederacy's sides. The war was sparked around the issue of slavery and its extension into the western territories of the United States. Seven so-called 'slave-states' in the South of the country seceded from the U.S. government and formed the Confederate States of America around the time of Lincoln's inauguration as the 16th President of the United States of America. In April 1861 the Confederates attacked Fort Sumter, an important fort held by the U. S. Government. Lincoln, a Republican, was opposed to the continuation of slavery and its expansion to other parts of the United States. The war dragged on for just over four years and saw over six hundred thousand people killed.

Over one hundred years ago the psychologists Robert Yerkes and John Dodson proved the relationship between human arousal (stress) and performance. While the Yerkes-Dodson law has undergone various enhancements over the last century, their basic premise remains intact: namely, that there is an optimum level of arousal where people perform at their best, and other levels where too little or too much stimulation results in lethargy and discontent or overload and breakdown.